Modifying Beliefs and Altering Behaviors: The Development of
Cognitive-Behavioral Therapy

Michael A. Stier

Abstract

There are over 240 psychotherapy and counseling
techniques currently in use within the United States but questions concerning
which therapy style is the most helpful have risen. Evidence-based practice was
implemented to structure therapy sessions based on techniques that have been
empirically researched for effectiveness. Due to the enforcement of
evidence-based practice, cognitive-behavioral therapy is growing in popularity
because of its cost efficiency, immediate results, and prominent client success.
The following research will compare the results of cognitive-behavioral therapy
to other commonly used therapy styles to assess effectiveness and time efficacy.
Although a vast majority of therapy models help clients in psychological
distress, it is important for insurance companies, clinicians, and clients to
recognize the notable difference between cognitive-behavioral therapy and other
commonly used therapy styles.

While therapy can be seen in forms such as
medicine or occupation, psychotherapy is commonly practiced by psychologists or
psychiatrists with clients who are normally in emotional or behavioral distress.
Although more than 44 million people suffer from mental health disorders (APA,
2005), two thirds of that population do not seek proper treatment for their
mental illnesses (APA, 2005). Trouble with insurance companies and difficulty
with money is the number one reason that individuals do not seek the proper
help; however, the second reason is commonly associated with the stigma of
seeing a mental help professional (APA, 2005). A stigma, as explained by
Heathline in 1999, is a Greek word that originates from a tattoo or mark that
was cut or burned into the skin of criminals, slaves, or traitors in order to
visibly identify them as blemished or a morally polluted person. Typically
people would not identify a person who is in psychotherapy as a �blemished or
morally polluted person,� which leads to the notion that the process of
psychotherapy is unfamiliar to most of the population. In other words, it seems
that psychotherapy is thought as demeaning to the client due to the unfamiliar
process that occurs. For instance, on a less significant level, a person may
constantly explain that he or she does not like a certain food such as sushi
even though he or she has never tried the food. Even though individuals have no
personal experience with sushi, they describe it as against their tastes because
it is unfamiliar to them.

According to Thombs (2006), psychotherapy can be
described as �professional services aimed at helping individuals or groups
overcome emotional, behavioral, or relationship problems� (p. 120). The process
of psychotherapy can be easily confused and misrepresented due to the multiple
forms of psychotherapy currently in practice. Some of these comparative and
conflictive forms of psychotherapy include psychoanalysis, cognitive-behavioral
therapy, Adlerian therapy, and existential therapy. The typical perception of
psychotherapy is usually visualized as a middle aged, white haired man listening
to the problems and concerns of a distraught client lying on an oversized brown
couch. This type of therapy, which is commonly mistaken for the process of
psychotherapy, is psychoanalysis. This type of therapy is based on having the
client tell stories from his or her past experiences that seemed to have
troubled him or her as well as any current issues that may be distracting him or
her. The therapist�s duty is to listen to and interpret these past stories into
current problems that clients may be experiencing. This form of psychotherapy
was introduced and reinforced by well known psychologist Sigmund Freud, who
devoted his practice to focus on the concept that unconscious factors motivate
behavior. Another type of psychotherapy is cognitive-behavioral therapy, founded
by Albert Ellis. Cognitive-behavioral therapy stresses the importance of
thinking and belief systems as the root of personal problems (Corey, G., 2009).
This therapy is not concerned with the client telling stories of his or her past
to the therapist, but is concerned with the therapist seeking to use both
cognitive and behavioral principles and methods to modify the client�s
maladaptive patterns. In other words, the therapist�s goal is to give the
clients healthier and more effective coping strategies to deal with problems he
or she may face throughout life as well as changing their belief system towards
the destructive qualities which the individual is attempting to overcome.

Some psychotherapy models, such as
cognitive-behavioral therapy, have gained an edge in practice through outpatient
clinics as well as with insurance companies due to support from empirical
evidence in regards to effectiveness of treatment and time efficiency.
Furthermore, evidence-based practice mandates the types of treatments that
therapists can offer which will be covered under the client�s insurance policy.
These treatments have been selected by the American Psychological Association
and insurance companies from the combination of testing treatment
effectiveness. It seems intuitive that treatments should be mandated as working
models before being used on clients. However, this type of practice has caused
problems within groups of therapists. For example, a general model of treatment
may be an excellent idea for some cases, but the argument arises in relation to
the generalization of treatment plans and accommodations for specific
characteristics of an individual client.

Psychotherapy methods can be as diverse as the
therapist being told a story to implementing cognition changes to the client�s
life. However, psychotherapy is not a place for advice or unconditional positive
reinforcement. The world is full of advice and, most of the time, the client�s
problem is deciding which advice to follow. The goal of psychotherapy is to give
the client�s own voice and opinions an opportunity to regain confidence and take
control of his or her life. The answer to the problems should not come from the
therapist, but from the client; the therapist must unlock those answers for the
client to use effectively. Therapy is not a massage and certainly not an easy
task for the client to endure as most times it can be uncomfortable and hurtful
to access certain periods in his or her life. However, if there is not a small
amount of discomfort within the therapy session, the client may not be making
any improvements in his or her current condition (Pologe, B., 2006).

The process of psychotherapy succeeds due to the
increased awareness of other agendas; consequently, the less aware of these
patterns of motives, feelings, thoughts, actions, and perceptions, the more they
control people�s behavior. The coping strategies for these adverse feelings
become outdated and are no longer effective with the individual (Pologe, B.,
2006). Although there are varying degrees of psychotherapy, a general definition
can usually be accepted: any treatment of mental, behavioral, or a relationship
problem that aids a client in recognizing his or her own maladaptive coping
strategies to produce a greater quality of life.

The differences between the varying therapy styles
have been adequately researched and analyzed to increase knowledge of treatment
success rates and improvement in time management. Zaretsky, Lancee, Miller,
Harris, and Parikh (2008) used a sample of 79 consenting adult men and women
with Bipolar Disorder on stable medication regimens to investigate the
difference between psychoeducation and cognitive-behavioral therapy. The sample
was randomized so the participants would either receive seven sessions of
individual psychoeducation, which is comparable to psychoanalysis, or seven
sessions of psychoeducation followed by 13 additional sessions of
cognitive-behavioral therapy. The client�s progress was reported by a
combination of weekly mood and medication reports as well as monthly assessments
for psychosocial functioning and mental health. They found that participants
who received cognitive-behavioral therapy in addition to psychoeducation
experienced 50% fewer days of depressed mood over the course of a year than
participants that received psychoeducation alone. Furthermore, participants in
psychoeducation were found to be prescribed more antidepressants throughout the
year compared to the participants that received both treatments (Zaretsky et
al., 2008).

Olmstead, Sindelar, Easton, and Carroll (2007)
examined the differences among different treatment options including
cognitive-behavioral therapy, contingency management, and drug counseling in
relation to the cost-effectiveness. They found that cognitive-behavioral therapy
with the addition of contingency management was the most cost-effective while
drug counseling was found to be the least cost-effective. Although contingency
management worked well with cognitive-behavioral therapy in the previous study,
Carroll, Nich, and Ball (2005) examined the role of homework assignments in
clients with dependency. A one-year follow up assessment of the clients
demonstrated that participants who had completed more homework assignments
significantly increased the quantity and quality of their coping strategies in
addition to using less cocaine throughout their treatment.

Cognitive-behavioral therapy is not only effective
in treating cases of substance abuse or dependency as exemplified by Petry, Litt,
Kadden, and Ledgerwood (2007), which examined the effects of
cognitive-behavioral therapy and support groups such as Gamblers Anonymous.
Participants were either referred to Gamblers Anonymous in addition to sessions
of cognitive-behavioral therapy or exclusively to Gamblers Anonymous. They found
that both treatment options decreased the client�s condition with gambling,
however, the use of Gamblers Anonymous and cognitive-behavioral therapy produced
larger success rates of lowering gambling addiction than the support group
alone. Results from this study seem sensible because although support groups are
helpful to individuals with problems of addiction, it cannot be considered
professional treatment.

Furthermore, Safren, O�Cleirigh, Tan, Raminani,
Reilly, Otto, and Mayer (2009) evaluated the impact that cognitive-behavioral
therapy had on medication adherence and reduction of depression in individuals
with HIV. Individuals who were receiving cognitive-behavioral therapy
significantly improved adherence to medication regiments and depression in
comparison to the control group. Moreover, individuals who were originally in
the comparison group chose to cross over to treatment with cognitive-behavioral
therapy and experienced similar results as the original experimental group.
Additionally, Rosell�, Bernal, River-Medina (2008) assessed the differences
between cognitive-behavioral therapy and interpersonal psychotherapy in a sample
of clients with depression symptoms. They concluded that both
cognitive-behavioral therapy and interpersonal psychotherapy are effective
treatment models for depression, but cognitive-behavioral therapy significantly
reduced the depressive symptoms and improved self concept much better than
interpersonal psychotherapy.

However, Litt, Kadden, Cooney, and Kabela (2003)
administered 26 weeks of either cognitive-behavioral therapy or interactional
therapy to 128 alcohol dependent men and women to assess coping skills and
drinking habits. Both of the therapy types used displayed very successful
drinking coping skills among the individuals. Neither treatment differed from
the other in terms of a greater increase of coping strategies, which questions
the advantages of cognitive-behavioral therapy over interactional therapy in use
with alcohol dependents.

Psychotherapy can appear in many diverse forms
including psychoanalysis, Gestalt therapy, and cognitive-behavioral therapy.
These therapy techniques are commonly used within outpatient clinics and
hospitals in addition to many years of successful application in private
practice. All of these methods have been found successful in treating mental
illness and reorganizing an individual�s life. However, it is apparent in
current research that therapy methods have been evolving, becoming progressively
more time efficient and impactful. For instance, according to Linehan,
Armstrong, Suarez, Allmon, and Heard (1991) in a study comparing
cognitive-behavioral therapy to other �common therapy methods,� they found that
patients who received cognitive-behavioral therapy had much lower rates of
inpatient days per year (M=8.46) than patients that received the common therapy
methods (M=38.86). In addition, cognitive-behavioral therapy significantly held
patients in treatment more effectively than with the other common therapy
styles. Even though both of the therapy methods described in the study
successfully helped the patients, it was apparent that cognitive-behavioral
therapy was more valuable in respects to time efficiency and patient return.

Austrian psychologist Sigmund Freud and his
followers developed an explanation of human behavior and psychological
functioning that was named psychoanalysis. Freud encouraged free association
which means that when patients arrive to therapy, they may speak about any
subjects they would like. This freedom of speech generates a relaxed atmosphere
between the therapist and patient in addition to lowering resistance experienced
by the patient. Freud posited that if a patient is relaxed, unconscious notions
will slowly drift towards the topic at hand, where the problem usually exists.
This type of therapy provides no aim or specific goals to accomplish within a
set time frame, making accomplishments in therapy directly associated to the
pace the patient provides. Furthermore, emphasis is placed in the patient�s past
experiences and the impact that remains in his or her current state (Boeree,
2006).

Arguments have been composed against
psychoanalysis because of the lenient timeline that provides only slight
foundation of therapeutic progression. In addition, many critics of
psychoanalytical therapy assert that it is not a science since it cannot be
measured in a specific form of succession. According to Popper (1986),
psychoanalysis cannot be considered a science because it is not falsifiable and
predictions of psychoanalysis are not calculations of evident behavior but of
discrete psychological states. Moreover, Colby (1960) explained that
psychoanalysis is not a science because it lacks the ability to predict future
or past experiences. For instance, psychoanalytical therapists claim that child
molestation or abuse will cause neurosis later in life. However, if this
statement could be considered valid, it would imply that any individual that has
been molested or abused as a child would acquire these specific neurotic traits.
On the other hand, if an individual possessed the specific neurotic traits, it
would imply that he or she was abused or molested during childhood. Neither of
these claims can be proven valid with any accuracy (Colby, 1960).

One of the theories that moved away from
psychoanalytic thought was Gestalt psychology founded by Max Wetheimer. However,
Gestalt therapy was founded by Fritz Perls in the 1960s to incorporate a more
global perspective. For instance, people and objects are not viewed separately,
but in conjunction with their surrounding atmosphere and cannot be separated
from that environment. Gestalt therapy focuses mostly on perception of
instinctive mental laws that govern how objects are perceived and brings all
therapeutic focus to the present moment. Concurrently, it is accepted by Gestalt
therapists that �the whole is different than the sum of its parts,� which is
critical in considering the client and environment (Corey, 2009).

Criticisms have been made against Gestalt therapy
that includes accusations to its confrontational approach. The therapy style
that Perls used includes provoking and confronting any current problems the
client may be experiencing. However, some argue that Perls and his followers can
be considered too confrontational with clients (Shepard, 1975). Equally
important, Gestalt theory lacks a distinct, clear, and fully elaborate theory of
development which hinders the understanding of theory compared to human behavior
in various stages of life. Developmental processes could be crucial in
understanding and interpreting current problems or situations a client may be
experiencing. Furthermore, the most criticized aspect of Gestalt therapy
includes the therapist�s role as a medium for change. If the therapist does not
have a strong personal commitment to the client and to following the Gestalt
principles, the therapeutic process will be significantly diminished (Lobb &
Salonia, 1993).

Although psychoanalytical and Gestalt therapy
models work to help clients progress to a greater quality of life,
cognitive-behavioral therapy is growing in popularity since the 1960s due to
Aaron Beck and Albert Ellis. Beck worked in conjunction with Ellis, founder of
Rational Emotive Behavioral Therapy, which focuses on an individual�s
experiences, beliefs, and finally consequences (Corey, 2009).
Cognitive-behavioral therapy is a short term therapy model that focuses on
practical solutions and using hands-on techniques to modify patterns of thinking
or behavior that reside behind the client�s difficulties. Cognitive-behavior
therapy works by changing an individual�s attitudes and behaviors by focusing on
thoughts, images, beliefs and attitudes that he or she holds. How an individual
attains this information relates to the way he or she behaves and deals with
emotional problems (Martin, 2007).

While psychotherapy and Gestalt therapy models
take years to complete, cognitive-behavioral therapy normally lasts four to
seven months for most emotional problems. Clients normally attend one session
per week and sessions normally last 50 minutes. Within the session, the
therapist and client work collectively to identify the problems and develop new
coping strategies to help with any future encounters. However, to many
professionals, cognitive-behavioral therapy is considered to be a combination of
psychoanalysis and behavioral therapy. Both aspects are needed for
cognitive-behavioral to be successful because psychoanalytical theory
establishes meaning within the conversation between the client and therapist
while behavioral therapy modifies meaning to produce a positive outcome (Martin,
2007).

According to Martin (2007), studies have shown
that cognitive-behavioral therapy can dramatically reduce the symptoms of many
emotional disorders. In addition, many studies have shown that individuals with
as little as 12 sessions of cognitive-behavioral therapy have found to be more
effective than being prescribed medication for a period of two years. This
suggests that cognitive-behavioral is not an immediate adjustment to emotional
problems, but a learning experience that encourages real change rather than
feeling better only when in session with the therapist (Martin, 2007). A study
conducted by DeRubeis, Gelfand, Tang, and Simons (1999) compared the progress of
therapy for individuals who were using cognitive-behavioral therapy and
individuals who were using medication to manage severely depressed clients. They
found that cognitive-behavioral therapy produced better results than taking the
medication alone. Moreover, Butler, Chapman, Forman & Beck (2006) found that
cognitive-behavioral therapy was superior on parameters of treating depression,
anxiety, anger, marital problems and was equally successful as the use of
antidepressants.

Through the information described above,
cognitive-behavioral is not a separate therapy style from psychoanalysis and
Gestalt therapy. Similar to most therapy styles, adaptations from previous work
and therapy are restructured to accommodate the therapist�s ideas and evolving
research. However, with the dramatic time efficacy and production of long term
behavioral changes that can be applied to any facet of the client�s life, it is
clear to see why cognitive-behavioral therapy styles are becoming more popular
with psychologists, psychiatrists, and insurance companies.